This Resident Roundup post comes from Sean Pirkle, MD. He offers his candid perspective on a question that other residents may also find themselves pondering.
A patient on one of my off-service rotations presented to care with what turned out to be a perforated duodenal ulcer. He was taken to the operating room shortly after arrival and was treated with an intra-abdominal omental flap. My chief liked to call it “nature’s safety net”; others know it as a Graham patch repair.
Following the recommendations of the gastroenterology consult team, our plan for the patient was to keep him strict nothing by mouth (NPO) for 3 days post-procedure, after which we would perform a swallow study to assess for any leakage of fluid. During rounds on post-operative day 2, we discovered that oral melatonin had been added to the medication administration record (MAR) by the overnight resident. The gallery had a field day:
“Who ordered this?”
“What the heck.”
“You’ve got to be kidding me.”
The next day went by uneventfully. When we signed out to the night float team, again, we reiterated the strict NPO orders: “Last night, meds were ordered for this patient. Please do not order anything for him tonight; he is strict NPO.” The following morning, we learned the same mistake had been repeated. The rage was palpable.
When I was a third-year medical student on my surgery rotation, the night float intern frequently made similar mistakes. I remember him tinkering around with overnight medications, and the day team, exasperated, would shake their heads through morning handoffs. A chief would storm into the room shortly thereafter asking who pushed a fluid bolus on a patient with heart failure without consulting their senior, and my residents would look up at them and respond, “Who do you think?”
I left this rotation terrified, not at the possibility of being the recipient of my future co-residents’ disdain but wondering whether I could be a bad resident without ever knowing it.
A year after this thought first intruded into my mind, I finished my orthopaedics sub-internship. Toward the end of the rotation, I came to the realization that my daily ritual included comparing myself to the intern. I knew I would be in their shoes in a few short months, and the speed at which this date was approaching frightened me. I knew I was not ready. At the conclusion of the rotation, I pulled aside one of my mentors to express these fears. I had prepared a long-winded speech, which he let me perform without interruption. When I had finished, he responded that I would be ready when the time came. Simple as that.
How could he be so sure?
In medical school, during school-wide meetings, the Dean of Students loved to reference the Yerkes-Dodson curve. The curve defined the relationship between stress and performance. He used it to explain the phenomenon wherein having no stress is detrimental because it allows trainees to be too comfortable (or lack motivation or attention to detail). On the other hand, too much stress can be crippling and negatively impact our ability to perform even the most rehearsed tasks. The key to success, he said, was finding that optimal middle ground between not caring and pathologic anxiety. He always conceded that this was easier said than done, “It is certainly a tighter bell curve than advertised.”
I think there is a lot of truth in that curve. It doesn’t change the fact that I’m afraid of unintentionally hurting patients, of taking on new responsibilities as the consult resident, and of eventually operating solo. I’m still scared that I might be a bad intern (or resident or surgeon) without ever knowing it, but while this may be the thing that keeps me up at night, I hope most days I do not succumb to the paralysis of fear; rather, I am driven by the discomfort of stress to go further, to study harder, to be a better surgeon. In time, I have found that with preparation, dealing with feelings of uncertainty has become more manageable.
Am I a bad resident? I am not sure and maybe only time will tell. But what I do know is that I am trying each day to be better than the last.
Sean Pirkle, MD, is a second-year resident with the Department of Orthopaedics and Sports Medicine at the University of Washington in Seattle.
OrthoBuzz looks forward to sharing additional posts by residents, and for residents, in the new Resident Roundup section.